Failure to Protect Resident from Physical and Mental Abuse by LPN
Penalty
Summary
Facility staff failed to protect a resident's right to be free from physical and mental abuse during an incident involving an LPN and a resident with multiple complex medical and psychiatric diagnoses, including severe vascular dementia, traumatic brain injury, and a history of agitation and behavioral disturbances. The resident, who was moderately cognitively impaired, became physically aggressive with staff and other residents, leading to an intervention by an LPN. According to multiple staff and witness statements, the LPN responded by grabbing the resident's arms aggressively, pushing the resident up against a desk, and then tilting the resident's wheelchair back onto two wheels in an attempt to move the resident down the hall. During this process, the resident continued to resist, and the LPN ultimately let go of the wheelchair, causing the resident to fall backward and strike his head on the floor, resulting in a contusion and a scalp hematoma. Documentation in the clinical record and facility incident reports indicated that the LPN's actions were physically forceful and included aggressive handling of the resident. Witnesses described the LPN as slamming the resident against the desk and making statements such as, "We aren't doing this," and, "If anyone wants to report me for abuse then so be it." The incident was corroborated by multiple staff statements and was reported to have caused both physical harm and mental distress to the resident. The resident was subsequently sent to the emergency room for evaluation of the head injury sustained during the fall. The facility's own investigation and staff interviews confirmed that the LPN's intervention escalated the situation and resulted in the resident's injury. The facility's abuse policy prohibits the willful infliction of injury or intimidation resulting in physical harm, pain, or mental anguish, and the actions taken by the LPN were found to be in violation of this policy. The incident was substantiated as abuse, and the LPN involved was not permitted to return to the facility following the investigation.